AUTHOR AND EDITOR INFORMATION

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INTRODUCTION

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Fracture of the medial condyle is rare in adults and in children; prompt recognition of this sometimes elusive injury is imperative so that complications can be averted.

Background

Frequency

United States

Trauma to the elbow has a high potential for complications and residual functional disability. Luckily, fractures of the humeral condyles are uncommon in adults. Medial condylar fractures are less common than fractures of the lateral condyle. Together, these injuries account for approximately 5% of all distal humerus fractures in adults.

During adolescence, the distal humerus is the second most common site of physeal injury (second only to the distal radius). Supracondylar fractures account for approximately two thirds of distal humeral injuries in children. In children with elbow fractures, isolated medial condyle fractures are uncommon and account for approximately 1-2% of all distal humerus fractures. In children, medial condyle fractures occur at a peak age of 8-12 years.

Fracture of the medial epicondyle of the elbow is common and occurs in approximately 10% of pediatric elbow fractures. Most of these injuries occur in males aged 10-14 years.

Functional Anatomy

The elbow joint is composed of the bony articulation between the humerus, ulna, and radius. The distal end of the humerus can be divided into the medial and lateral condyles. The articular portion of the medial condyle is the trochlea, and the articular portion of the lateral condyle is the capitulum. The epicondyle is considered part of the nonarticular portion of the condyle. The dividing point for the distal humerus, separating the medial and lateral condyles, is the capitulotrochlear sulcus.

Distinguishing between the articular and nonarticular surface of the condyles is important in the diagnosis and management of condylar fractures. By definition, fractures that involve only the intra-articular surface have no muscular attachments and can only be repositioned by pressure of the opposing articular surface or by open reduction and internal fixation. Fractures that extend beyond the joint capsule have attached muscle and ligaments. The position of the fracture fragment is often influenced by its muscular attachment.

The stability of the elbow is enhanced by its surrounding ligamentous structures. The medial collateral ligament and the lateral collateral ligament (ie, ulnar collateral ligament, radial collateral ligament) provide further stability of the elbow. The radiocapitellar joint is supported by the radial collateral and annular ligaments.

Collectively, the forearm musculature originates from the bony epicondyle prominences. The wrist flexors originate from the medial epicondyle, and the wrist extensors originate from the lateral epicondyle. Because the forearm musculature traverses the elbow joint, some inherent stability to the joint is conferred by muscular contraction.

The structures of the upper arm and elbow are located in either the anterior or posterior compartments. The anterior compartment contains the biceps brachii, brachialis, and coracobrachialis muscles. The anterior compartment also contains the brachial artery, median nerve, musculocutaneous nerve, and ulnar nerve. The ulnar nerve passes behind the medial condyle as it enters the forearm. Because of its location and relatively tight tethering to the epicondyle, the ulnar nerve can be injured when the medial humeral condyle is fractured. The posterior compartment contains the triceps brachii muscle and the radial nerve.

The bony anatomy of the elbow in the pediatric population deserves special mention. Many of the challenges encountered in diagnosing elbow fractures in pediatric patients involve proper knowledge of the ossification centers of the elbow. In general, ossification of the growth centers begins at an earlier age in girls than in boys. Although variation exists, ossification of the growth centers of the elbow occurs at the following times:

• Capitellum - 11 months



• Medial epicondyle - 4-6 years



• Radial head - 5-6 years



• Olecranon - 6-8 years



• Trochlea - 9-10 years



• Lateral epicondyle - 10-12 years

Sport Specific Biomechanics

By definition, the elbow is a true hinge joint that is very stable to all motions except varus and valgus stress. The articulation of the trochlea of the humerus and the olecranon of the ulna defines the plane of flexion and extension at the elbow. The elbow also allows for pronation and supination at the radiocapitellar articulation. The radiocapitellar joint does provide some stability against valgus stress by acting as a buttress to prevent medial elbow opening. Stability is further enhanced by the strength of the ulnar collateral ligament, the principal stabilizing ligament of the elbow that resists valgus stress.

The radial-collateral ligament protects the joint from posterolateral rotary instability and is usually injured during elbow dislocation. The wrist extensor tendons that originate on the lateral intermuscular septum of the arm and the lateral epicondyle provide the elbow with stabilization against varus stress.

CLINICAL

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History

• When evaluating a patient with an acute elbow injury, obtain a detailed event history including the injury mechanism and the quality, intensity, duration, and location of symptoms.
  
  
  • Injuries to the upper extremity, specifically the elbow, are often caused by falling on an outstretched arm, with the elbow in extension and the wrist in dorsiflexion. This type of injury can cause the medial condyle of the elbow to be avulsed as a result of ligamentous and muscular forces.
  
  
  
  • Another mechanism responsible for medial condylar fractures is falling onto the point of a flexed elbow. The direct force applied to the posterior aspect of the elbow causes the articular portion of the olecranon to push the medial condyle off the distal humerus.
     
• Elicit and document hand dominance, occupation, and preexisting extremity injury.



• Also obtain a history of neurovascular complaints (eg, paresthesias, weakness, numbness, coolness). Neurologic complaints associated with acute elbow trauma suggest a neurapraxia, nerve entrapment syndrome, or compartment syndrome.

Physical

• Visual inspection is often the first step in assessing a patient with a traumatically injured elbow.



• Evaluate all injured patients in a systematic fashion as described in the Advanced Trauma Life Support provider's manual. The athletic trainer or examining physician should be aware of the possibility of a proximal upper extremity injury (ie, fracture, dislocation) in patients who have fallen onto an outstretched upper extremity.



• Systematically perform the physical examination of an acutely injured extremity. In the patient with an acutely injured elbow, evaluation of the extremity can begin at the shoulder and upper arm and then proceed to the forearm, wrist, and hand. The elbow should be examined last because tenderness elicited may interfere with a proper examination of the injured extremity.



• Assess the vascular status of the extremity. Palpate brachial, radial, and ulnar pulses. Evaluate the injured extremity for signs and symptoms of a compartment syndrome, including pain out of proportion to the injury, severe forearm pain with passive extension of the fingers, pallor, paresthesia, pulselessness, and paralysis.



• Test neurologic function. Perform distal motor and sensory testing of the radial, median, and ulnar nerves.
  
  
  • Radial nerve testing
    
    
    • Motor function of the radial nerve can be assessed by testing finger extension, which is primarily a function of the C7 nerve root.
    
    
    
    • Sensory testing can be performed over the dorsal web space between the first and second digits.
       
  • Median nerve testing
    
    
    • Motor function of the medial nerve can be assessed by testing finger flexion, which is primarily a function of the C8 nerve root.
    
    
    
    • Sensory testing can be performed over the radial aspect of the second digit.
       
  • Ulnar nerve testing
    
    
    • Motor function of the ulnar nerve can be assessed by testing finger abduction, which is primarily a function of the T1 nerve root.
    
    
    
    • Sensory testing can be performed over the ulnar aspect of the fifth digit.
       
• Range-of-motion testing prior to radiographic evaluation should be minimized in the acutely painful extremity, especially in children.

Causes

Medial condylar fractures generally occur as a result of (1) a fall onto an outstretched upper extremity or (2) a fall onto a flexed elbow. The mechanism of injury appears to be the same in both children and adults.

DIFFERENTIALS

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Other Problems to be Considered

Supracondylar fractures of the humerus
Medial epicondylar fractures
Olecranon fractures

WORKUP

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Lab Studies

• Laboratory studies are not generally indicated for diagnosing condylar fractures of the elbow.

Imaging Studies

• Radiography
• • Standard elbow radiographs, which include anteroposterior and lateral projections, are often sufficient to diagnose a fracture in the acutely injured elbow. Additional views (eg, oblique projections) are rarely required.
  
  
  
  • The decision to obtain elbow radiographs is based on the history of the injury and the physical examination findings from the patient. Clinical decision rules, such as the Ottawa ankle and foot rules (commonly used in emergency medicine), that help identify which patients with acute traumatic elbow injuries need radiographs have not yet been developed.
  
  
  
  • Radiographs should be performed on patients who exhibit joint swelling and tenderness of the bony landmarks, crepitus, or restricted and painful range of motion of the elbow following trauma.
  
  
  
  • In condylar fractures, the radiograph typically reveals widening of the intercondylar distance. Although the fracture fragment may be displaced proximally, it is generally seen inferior and posterior to its normal position.
  
  
  
  • In young children, medial condylar fractures may be difficult to diagnose radiographically if the injury occurs before ossification of the trochlea. Clinically and radiographically, the injury may be misinterpreted as a fracture of the medial epicondyle.
  
  
  
  • In older children, a metaphyseal fragment may be visualized, indicating condylar involvement. The presence of a pathologic fat pad, either a large anterior fat pad (sail sign) or a posterior fat pad, often indicates an intra-articular injury. Isolated fractures of the medial epicondyle are extra-articular injuries and are not commonly associated with the presence of a posterior fat pad sign. In the clinical context of acute elbow trauma without an obvious fracture on the radiograph, a pathologic fat pad is often associated with the presence of an occult fracture.
  
  
  
  • Plain films may be difficult to interpret in pediatric patients, and comparison views of the uninjured extremity may help to differentiate a fracture from a secondary ossification center.
  
  
  
  • Radiographically, medial condylar fractures are classified the same as lateral condylar fractures. Fracture classification is primarily based on the location of the fracture line. In adults, Milch classifies medial condylar fractures into 2 types (type I or type II) depending on whether the lateral wall of the trochlea remains attached to the humerus.
    
    
    • Type I fractures are more common. In this type of injury, the fracture line originates at the depth of the trochlear groove and ascends obliquely toward the supracondylar ridge. In type I fractures, the lateral trochlear ridge remains with the intact condyle, maintaining mediolateral stability.
    
    
    
    • Type II fractures originate in the capitulotrochlear sulcus, thus leading to mediolateral instability of the elbow.
       
  • The Milch classification can also be applied to pediatric medial condylar fractures.
    
    
    • A Milch type I fracture is a Salter-Harris type II fracture. In this injury, the fracture line runs between the common physeal line, separating the medial and lateral condylar ossification centers.
    
    
    
    • A Milch type II fracture is a Salter-Harris type IV fracture. The fracture line traverses the medial aspect of the lateral condylar ossification center.
       
  • Classification of medial condyle fractures in children is further subdivided based on the displacement of the fracture as described by Kilfoyle. Three fracture patterns have been described.
    
    
    • Kilfoyle type I is a nondisplaced fracture through the medial condylar metaphysis extending down to the physis. Type I fractures do not extend into the articular surface.
    
    
    
    • Kilfoyle type II fractures are also nondisplaced. The fracture line extends through the articular surface of the medial condylar physis.
    
    
    
    • Kilfoyle type III fractures involve displacement and rotation of the distal condylar fracture fragment.
       
• Arthrography: On occasion, an elbow arthrogram may be used to help the physician clarify a fracture that is difficult to visualize because of an unossified condyle.



• Ultrasonography and magnetic resonance imaging: These studies have also been used to further evaluate the unossified epiphysis in patients with traumatic elbow injuries.

Procedures

• Arthrocentesis
• • Distention of the elbow joint by an acute traumatic hemarthrosis is often painful; its presence may limit proper evaluation of the injured elbow. Therapeutic arthrocentesis to relieve a painful posttraumatic effusion is considered an acceptable practice. Diagnostically, arthrocentesis may help identify an occult fracture based on the presence of fat globules mixed with the aspirated blood.

  • Elbow arthrocentesis should be performed using an aseptic technique. The elbow is approached laterally through the radiohumeral joint. The elbow should be mostly extended, and the forearm should be held in a neutral position. The depression between the radial head and the lateral epicondyle of the humerus should be palpated. The needle is inserted just distal to the lateral epicondyle and is directed medially. Some authors recommend flexing the elbow to 90° and pronating the forearm prior to inserting the needle.

TREATMENT

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Acute Phase

Medical Issues/Complications

• Acute complications

• Neurovascular complications can occur as a result of medial condylar fractures. One of the most feared acute vascular complications is the development of a compartment syndrome. As a result of bleeding and swelling in a closed fascial space, compartment pressures rise, circulation is compromised, and tissue hypoxia and ischemia can ensue.

• The ulnar nerve enters the forearm as it passes behind the medial condyle. Fractures in this region place the ulnar nerve at considerable risk for injury.

• Failure to make the proper diagnosis during the initial evaluation can complicate the management of these injuries. In young children, the proper diagnosis of a medial condyle fracture may be challenging. This is especially true in cases in which the trochlear epiphysis has not yet ossified. A delay in diagnosis often increases the likelihood of delayed healing or functional disability.

• Early displacement of the fracture fragment can occur in fractures that are managed by closed-reduction methods.

Surgical Intervention

The goal of treatment is to obtain proper reduction of the fracture fragment in order to restore alignment of the articular surface of the distal humerus. Fractures demonstrating 2 mm or more displacement generally require surgical fixation; closed reduction is difficult to achieve and maintain. Residual displacement is poorly tolerated. Some authors recommend anterior transposition of the ulnar nerve if the fracture involves the ulnar groove or if the nerve is injured.

Consultations

Refer patients with medial condylar fractures for evaluation by an orthopedist. Nondisplaced medial condylar fractures can be splinted during the patient's initial emergency department evaluation in a long arm posterior splint; refer the patient for outpatient follow-up in 2-3 days. Displaced fractures require more urgent referral to an orthopedist for surgical fixation.

Other Treatment

• Long arm posterior splint
  
  
  • A type I injury with a nondisplaced fracture fragment is often initially treated with either a long arm posterior splint or a long arm cast, followed by referral to an orthopedist.
  
  
  
  • Patients with medial condylar fractures are splinted with the affected elbow flexed, the forearm pronated, and the wrist held in a flexed position. The reason for this positioning is to help relieve the tension on the forearm flexor muscle attachments. The long arm posterior splint prevents flexion and extension of the injured elbow.
  
  
  
  • Follow-up radiographs are taken within 5-7 days and weekly thereafter 3 times to ensure that delayed displacement of the fracture fragment is not present.
  
  
  
  • Immobilization is recommended for 4-6 weeks, followed by range-of-motion exercises.

• A double sugar-tong splint
  
  
  • A double sugar-tong splint is an alternative to the long arm posterior splint.
  
  
  
  • In addition to preventing flexion and extension, the double sugar-tong splint prevents pronation and supination of the forearm.
  
  
  
  • This may be preferred for more complex or displaced fractures of the elbow.

Recovery Phase

Rehabilitation Program

Physical Therapy

Barring any other traumatic injury, the patient should maintain general fitness during the rehabilitation phase of treatment, if possible. After the initial period of immobilization, initiate active assisted range-of-motion exercises. Forceful manipulation of the joint should be avoided in order to lessen the occurrence of heterotopic calcification. Implement progressive resistance training once motion is restored, with the goal of reaching preinjury strength and flexibility.

MEDICATION

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The medications used in the management of elbow fractures include analgesics, either oral or parenteral. In addition, oral nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, may confer some protection against the formation of heterotopic ossification. Conscious sedation may be required for the initial closed reduction of a fracture. Intravenous sedative and narcotic agents are commonly used to perform conscious sedation.

Drug Category: Analgesics

Adequate analgesia is an important aspect of patient care. For mild to moderate pain, oral anti-inflammatory/analgesic medications are used. Parenteral analgesia is usually required for patients with severe pain.

Drug Category: Benzodiazepines

Act in the spinal cord to induce muscle relaxation. Can provide proper sedation in order to achieve closed reduction of a fracture. Sedatives work synergistically with parenteral narcotic medications.

FOLLOW-UP

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Return to Play

Prior to returning to athletic competition, the participant should regain normal or near-normal strength in the affected arm and range of motion should be similar to the preinjury status. However, some athletes may be able to return to competitive sports prior to reaching these goals. This depends on the type of sport (ie, contact vs noncontact) and whether the injury affected the athlete's dominant or nondominant arm. Athletes returning to sports that require elbow-loading maneuvers (eg, gymnastics) often require more extensive rehabilitation prior to returning to competition. The use of bracing, to protect the elbow against valgus loads, is recommended for rigorous sports if return to play occurs before 6 months postinjury.

Complications

Delayed complications occur with a reasonably high frequency.

Limited flexion and extension is a complication that can occur with medial condylar fractures. Heterotopic ossification may occur and is related to trauma to the brachialis muscle. Usually, pronation or supination is not limited. Mild limitations of elbow movement are usually well tolerated from a functional standpoint.

Cubitus varus (gun stock deformity) can occur and may be the result of decreased growth of the trochlea. This complication may be more likely to occur in displaced fractures that receive no initial treatment.

Cubitus valgus deformities also can occur and appear to be due to secondary stimulation or overgrowth of the medial condyle fracture fragment.

Nonunion/pseudoarthrosis of the fracture fragment can occur as a complication of medial condylar fractures in children. This may be related to the precarious blood supply of the distal fragment and because fractures that traverse the physeal plate are inherently less stable.

Posttraumatic arthritis due to chondral injury or residual joint incongruity may occur; it usually manifests several years later. Avascular necrosis may ensue because of the poor vascularity of this area and has been reported for even nondisplaced fractures.

Prevention

Because these injuries occur as a result of accidental falls or participation in high-risk sports, prevention is difficult. Proper education and adequate protective gear (eg, elbow padding) should decrease the likelihood of these injuries occurring.

Prognosis

The outcome of medial condylar fractures depends on the degree of comminution of the fracture, the accuracy of the reduction, and the stability of fixation of the fracture fragment restoring congruity of the articular surface.

In general, nondisplaced fractures that are managed conservatively with a long arm cast have excellent results. In displaced fractures that require open reduction and internal fixation, a good outcome can be expected, with results paralleling the quality of reduction.

Education

For excellent patient education resources, visit eMedicine's Breaks, Fractures, and Dislocations Center and Sports Injury Center. Also, see eMedicine's patient education articles Broken Arm and Elbow Dislocation.

MISCELLANEOUS

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Medical/Legal Pitfalls

• The diagnosis of medial condylar fractures can be a challenge in the young child. An understanding of the skeletal development and radiographic findings at different ages can be important in the diagnosis and management of pediatric elbow fractures. Familiarity with the appearance of the ossification centers of the pediatric elbow should decrease the likelihood of a misdiagnosis.
• In children, nonaccidental trauma should be considered if the injury appears to be inconsistent with the history or inconsistent with the developmental stage of the child.

MULTIMEDIA

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Media file 1:  Milch classification of condylar fractures.
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REFERENCES

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• Bensahel H, Csukonyi Z, Badelon O, Badaoui S. Fractures of the medial condyle of the humerus in children. J Pediatr Orthop. Jul-Aug 1986;6(4):430-3. [Medline].
• Flynn JM, Sarwark JF, Waters PM, Bae DS, Lemke LP. The surgical management of pediatric fractures of the upper extremity. Instr Course Lect. 2003;52:635-45. [Medline].
• Fowles JV, Kassab MT. Displaced fractures of the medial humeral condyle in children. J Bone Joint Surg Am. Oct 1980;62(7):1159-63. [Medline].
• Geiderman JM, Magnusson AR. Humerus and elbow. In: Rosen P, Barkin R, eds. Emergency Medicine Concepts and Clinical Practice. 4^th ed. St. Louis, Mo: Mosby-Year Book; 1998:690-708.
• Ghawabi MH. Fracture of the medial condyle of the humerus. J Bone Joint Surg Am. Jul 1975;57(5):677-80. [Medline].
• Green NE, Swiontkowski MF, eds. Fractures and dislocations about the elbow. In: Skeletal Trauma in Children. 2^nd ed. Philadelphia, Pa: WB Saunders Co; 1998:294-301.
• Leet AI, Young C, Hoffer MM. Medial condyle fractures of the humerus in children. J Pediatr Orthop. Jan-Feb 2002;22(1):2-7. [Medline].
• Lins RE, Simovitch RW, Waters PM. Pediatric elbow trauma. Orthop Clin North Am. Jan 1999;30(1):119-32. [Medline].
• Nirschl RP, Kraushaar BS. Assessment and treatment guidelines for elbow injuries. Phys Sports Med. May 1996;24(5):43-60.
• Papavasiliou V, Nenopoulos S, Venturis T. Fractures of the medial condyle of the humerus in childhood. J Pediatr Orthop. 7(4):421-3. [Medline].
• Simon RR, Koenigsknecht SJ. Distal humerus. In: Emergency Orthopedics. 3^rd ed. Stamford, Conn: Appleton & Lange; 1995:147-168.
• Tsai AK, Ruiz E. The elbow joint. In: Ruiz EE, Cicero JJ, eds. Emergency Management of Skeletal Injuries. St. Louis, Mo: Mosby-Year Book; 1995:221-250.
• Wilkins KE. Fractures and dislocations of the elbow region. In: Rockwood CA, Wilkins KE, King RE, eds. Fractures in Children. 3^rd ed. Philadelphia, Pa: JB Lippincott; 1991:509-828.

Article Last Updated: Apr 28, 2006